Photos by Sudharak Olwe | Text by Priya Pathiyan
The Government of India’s Ministry of Health and Family Welfare has established 1,151 Nutritional Rehabilitation Centres (NRCs) across the country under the National Health Mission. They provide facility-based care for children with Severe Acute Malnutrition (SAM) and medical complications. As per the National Family Health Survey (NFHS 4, 2015-16), 7.5 per cent of children under five are severely wasted, and 35.8 per cent of children are underweight.
Children with Severe Acute Malnutrition along with medical complications are referred from villages by frontline workers, such as Accredited Social Health Activist (ASHA), and Anganwadi workers, and are admitted to NRCs as per the defined admission criteria. These NRCs offer appropriate feeding of children, careful height and weight monitoring, and counselling to mothers and caregivers on age-appropriate caring, nutrition and growth monitoring. The frontline workers actively make home visits and scan the Anganwadi Centres in the villages under their purview, to keep track of children’s health and spot those who need facility-based care. They are the ones who recommend admission to the nearest NRC.
Nutritionists that we met at the NRCs in Assam and Chhattisgarh were passionate about their work and used innovative means to explain the importance of a balanced diet for children to their mothers. Sadly, as there aren’t enough of these centres, and usually just about 10-12 beds in each, the wait is often long, thereby discouraging parents. NRC functionality differs from area to area, depending on the quality of training imparted to the staff, equipment provided, among other factors. Regular and periodic review of NRC functionality is supposed to be carried out under the child health programme by central and state government teams, who provide specific recommendations for improvement of functionality and quality of service delivery. According to reports received from various states and union territories, 1.86 lakh children under five years of age were admitted in the NRCs in the year 2017-18, of which 1.17 lakh children were discharged with target weight gain, so there is hope for success, along with scope for improvement.
We visited several NRCs and spoke to many of the hopeful mothers whose children are admitted there.
Kharupetia, Darrang, Assam
The Kharupetia NRC has 10 beds that are not nearly enough to accommodate SAM children from the 75 surrounding villages. Aditi Talukdar, the nutritionist here, explains how the young ones are fed a basic diet for the first three days, and then a ‘catch-up diet’, which is formula-based, and works wonders. Lina Parbin, who was born weighing three kilos, has certainly shown a marked improvement during her stay at the Kharupetia NRC in just 12 days. Once she completes 21 days, the one-year-old, who currently weighs 8.1 kilos, will probably reach the target weight of 9.4 kilos. Homemaker Arjuma Begum and driver Sofiqul Islam are optimistic that their daughter will then remain in better health.
At 14 months, Ekramal Haque weighs 5.6 kilos. The youngest of three siblings, he has just been brought to the NRC by his 35-year-old mother, Juhura Begum. Despite being a housewife and breastfeeding him on demand, the mother hasn’t been able to provide enough nutrition for her son. Her 45-year-old husband is a labourer who manages to earn only about Rs 200 a day, which doesn’t cover the family’s needs. Ekramal has had fever, urinary problems, vomiting, cough, changes in his skin’s appearance, and general lethargy over the last few months. They are hoping for a miracle at the NRC.
Said Amin sleeps fitfully inside a mosquito net. The 22-month-old was born underweight (just two kilos, 118 grams), and weighs only 8.750 kilos even now. Homemaker Rubia Begum, 35, and 40-year-old Mohammed Farhar Ali, a farmer, have only Rs 300 a day to spend on their family of four that lives in Assam's Sanowa village.
Twinkle is six months old, with an unmistakeable glint in her eyes when she smiles. Her mother Asha, much like her name, is hopeful that her daughter’s weight will stabilise after visiting the NRC. They have come from Kurutola that lies 35 kilometres away. Twinkle, who was born 3.5 kilos, has had a lot of weight fluctuation, but has fortunately not fallen sick, and has her mother breastfeeding her on demand. However, the fact is, Asha herself is anaemic and underweight, the staff nurse, Yogita Nag, points out. She is hoping that after eating some nutritious food cooked daily by Rajkumari Pajbie, the mother will be able to ensure her daughter’s wellbeing.
Shalini Suri too is extremely underweight, as is evident from her poor background. Her husband does bamboo work whenever he gets an opportunity. The doctors believe that their one-year-old daughter Lavanya only has a 42 per cent chance of survival.
Against all odds
Rekha Mundah has swaddled her tiny two-month-old baby Bhoni, so much so that all you can see at first are a pair of extra-bright eyes. The hard-of-hearing mother is understandably protective of her prematurely born child who weighed just 1,050 grams at birth, and has gained less than 800 grams since. Hailing from Assam's Khumtai village, they are at the only NRC in the entire district of Golaghat, which is located inside the Moran Tiloi community health centre. Bhoni’s chest X-ray and other medical reports echo what the naked eye can already tell — that she’s a SAM child, whose only hope for survival is the top feed and monitoring at the NRC, as her malnourished mother’s milk hasn’t been enough for her recovery. Nutritionist Prarthna Sonowal is confident that rapid improvement is possible at the NRC even in such extreme cases. But the problem is that the parents are not able to offer sustained nutrition once they go back home, she points out.